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The United Nations has grossly underestimated the number of people living under siege by both the Assad government and rebel forces, a Syrian medical association has charged.

In a report entitled “Slow Death”, the Syrian American Medical Society (SAMS) said 640,200 Syrians are currently living in at least 49 besieged communities across Syria, more than three times the U.N. estimate as of February 2015. “The 212,000 number cited by the U.N. is much lower than what everyone is seeing and experiencing,” Valerie Szybala, the report’s author, told Syria Deeply.

Some communities in Syria have been living under intense sieges for more than two years. Hundreds of thousands of Syrian civilians are being intentionally denied access to food and water and face indiscriminate and continuous aerial attacks that target civilian infrastructure including hospitals, schools and water/power systems, while medical personnel are purposely targeted for providing aid to civilians.

The SAMS report claims the U.N. is using too narrow a definition for besieged communities, and critiqued the international community for allowing the suffering of Syrians living under siege to metastasize for far too long.

“It’s completely unacceptable to just ignore the besieged areas, and that’s what is happening right now,” she said.

The sieges – largely perpetrated by the Syrian government against its own people – have led to death by starvation, dehydration and the lack of medical care, the report found. In a particularly grim example, it said a number of people are believed to have died from ingesting toxic vegetation while foraging for tree leaves and wild plants after local food supplies ran out.

Despite the deterioration of conditions inside Syria, “access to the besieged areas for humanitarian assistance is limited or nonexistent as any international efforts to end the sieges remain completely dependent on the besieging party for approval,” Szybala said.

She spoke to Syria Deeply about the conditions facing Syrians living under siege and the importance of reframing the way that the international community thinks about Syria’s besieged areas.

Syria Deeply: By your estimates, how many people are living under siege inside Syria?

Szybala: As of February 2015, the U.N. secretary-general’s reporting officially recognized 11 besieged areas in Syria with a combined estimated population of 212,000. With no independent statics regularly available, these figures have come to play a crucial role in framing the international community’s understanding of the siege crisis in Syria. The information presented in Slow Death indicates that the actual number of people living under siege is more than 640,200 in a total of 49 communities.

The report also contains a data set with information on 560 individuals who have died of non-military causes in besieged areas of Syria from the beginning of the crisis until the end of January 2015. We were conservative in our methodology, and our numbers were still three times higher than the U.N.’s numbers. For example, if there was any indication that an individual was a member of a military group who died because of malnutrition, we didn’t include them in our estimates.

We were also unable to provide estimates for an additional 20 locations inside Syria that could be under siege because we didn’t have good population estimates for them.

Syria Deeply: How are sieges used as a tactic of war inside Syria?

Szybala: Food, water, electricity and medical supplies are intentionally withheld from large civilian populations as a method of collective punishment. Checkpoints on all roads and exit points are imposed, and in some cases sieges have been going on for multiple years. The “starve or surrender” tactic differs based on how intense the siege is, and whether the area under siege is within urban or rural territory.

Syria Deeply: Who is enforcing the sieges?

Szybala: Sieges have been systematically imposed with increasing intensity and duration by the Syrian government on communities across the country. Opposition-controlled parts of the Damascus countryside have endured the harshest and most devastating sieges of the entire Syrian conflict. More than 90% of siege-related victims captured in the data set died in Damascus and its surrounding countryside.

Over 60% of the 560 victims in the dataset were from just two locations in the Damascus area: Yarmouk, with 173 victims, and Douma with 172.

Besieged areas are also continuously attacked by missiles and bombs. Douma, for example, has been undergoing some of the fiercest bombardment since the beginning of the war and is also enduring one of the harshest sieges.

Of the multiyear sieges, the only ones being enforced by rebel groups, including Ahrar al-Sham and Jabhat al-Nusra, are in Nubl or Zahraa in northern Aleppo governorate. However, only 8% of besieged people in Syria live in those areas.

We were not able to find a single casualty from the sieges in Nubl or Zahraa sieges, despite the fact that Nubl and Zahraa are the only locations in Aleppo that the U.N. has ever recognized as besieged. One hundred percent of the recorded deaths under siege were in areas besieged by the Syrian government. It doesn’t necessarily mean there aren’t any deaths associated with the rebel-held areas, but if there are, they haven’t been publicly documented.

Syria Deeply: How are people surviving? How are they meeting their most basic needs for food, water, and electricity?

Szybala: In a lot of places, people have relied on what they can produce locally. However, the Syrian government has targeted their fields, firebombing them right before harvest, to deprive people of resources.

After realizing that the electricity was not going to come back and major food shipments weren’t coming in, people turned to creative methods to survive. Medically, local physicians that have remained in the area are trying to manufacture their own supplies, like saline solution or jerry-rigging splints for bones.

Syria Deeply: What are the physical and psychological impacts on the civilian population? Who is most vulnerable?

Szybala: The physical and psychological effects are overwhelming. There is no real way to describe the suffering. Everyone under siege has lost weight, and many people have died a very slow and gruesome death as a result of malnutrition and starvation.

Mental health is a major casualty of war in Syria. SAMS’s doctors estimate that most of the Syrian population is suffering from some level of post-traumatic stress disorder, depression or shock. Emotionally, everyone is impacted; everyone’s lifestyle has been changed. Some children have known nothing other than siege, and it’s yet to be seen how that experience has taken a toll on them.

People are weakened from lack of food, unsanitary conditions, and there is no fuel to keep them warm. We have seen cold-related deaths like hypothermia and have also deaths caused by suffocation, because people are building fires inside by burning trash and wood to stay warm, which is also leading to deforestation.

You sense the level of desperation when you read about death caused by cases where people are desperate enough to scavenge and eat wild plants off the ground. There was a case of a man who died because he ate grass off the ground that was contaminated by arsenic. Because of the nature of siege, which is long-term deprivation of the necessities to survive, the people who are most physically vulnerable tend to succumb first – the children, infants, the elderly, and in some cases fetuses or mothers who weren’t able to cope with a pregnancy.

Syria Deeply: How has the collapse of the medical system made conditions worse? What are some of the challenges facing doctors trying to treat those living under siege?

Szybala: The biggest challenge for doctors is the fact that there aren’t enough doctors left, in large part because they are intentionally targeted, in an attempt to deprive the civilian population of medical care. Doctor’s homes are bombed and hospitals supported by SAMS have been hit not just by barrel bombs but intentionally targeted by missiles.

In a lot of cases, we have untrained or undertrained personnel treating people, which lower the availability and quality of care. There is also a lack of basic medical supplies such as anesthesia and blood transfusion bags, which are in shortest supply. Women are giving birth without anesthesia medication and surgery is performed without any medication to stop the pain. As an example of the implications of the lack of medical supplies – in June 2013, after the Syrian government withdrew ground forces from Douma and besieged the city, it destroyed the Douma public hospital in an airstrike.

Medical staff was able to salvage six dialysis units, which were distributed to six different locations in Douma so that they could not all be destroyed in a single attack. However, recently there has been a decline in available supplies even in Damascus proper and an increase in the strictness of the siege enforcement. Medical teams in Douma have alerted us that they will run out of all remaining dialysis supplies in the next week. All of their remaining patients will die within days of dialysis treatments ending.

Syria Deeply: How is the lack of water and electricity affecting the ability to treat people and leading to the rise of diseases?

Szybala: There are hospitals that can’t run their basic machinery and equipment. People are performing surgeries with primitive tools under flashlight or cellphone light because of lack of electricity. In some places like Eastern Ghouta, electricity has been off for years. The only other option is to use generators, but fuel for generators is incredibly difficult to come by and is very expensive to buy. Field hospitals have bought up a lot the fuel supply, which has caused resentment among civilians because there is not enough left for their needs. On the other hand, civilians recognize that the fuel is needed to run basic medical equipment, which is saving lives. It’s a very difficult situation. The lack of clean water and water treatment in besieged areas has led to the rise of diseases and epidemics of preventable diseases like typhoid, which hadn’t been seen in Syria for years before the conflict. Besieged areas unfortunately don’t benefit from the U.N. shipments of water and hygiene supplies.

Syria Deeply:How have prices of food and water supplies increased as a result of the siege? Is there a siege economy? Who is benefitting?

Szybala: There is certainly a black-market economy in Syria – it’s another window to life under siege. Where there is great need there is great profit to be made, and smugglers affiliated with armed groups have taken full advantage of the siege economy by forming cartels and engaging in price gouging. Armed groups stockpile goods and keep them out of circulation for civilians. In rural Damascus, we’ve seen reports that the Syrian government has allowed smuggling more regularly through checkpoints in the summer and most likely are recipients of the tariffs imposed on the smuggled goods. In the winter, the government has tightened the sieges when the effects of sieges would be harsher anyways due to the weather and lack of locally grown produce. The price of goods is generally much higher in besieged areas, and it skyrockets in the winter when the goods are needed most.

Syria Deeply: How many areas under siege have actually been reached by international assistance?

Szybala: The resolutions guaranteeing cross-border aid access to Syria haven’t made an impact on areas under siege. We’ve actually seen a slight decrease in what was already pretty nominal aid access to besieged areas since the U.N. resolution was passed, calling for cross-border aid without government approval.

As of January 2015, only two besieged areas were reached with international assistance, and the amount of aid sent in was enough for only 0.7% of the U.N.’s estimated 212,000 people living under siege, the report found.

Most requests to send aid to besieged areas are rejected. The U.N. and other agencies have continuously asked for permission, but asking the perpetrator of sieges for permission to help its victims is not an effective way to actually help them. As long as permission remains in the hands of the perpetrator of the crime, we are not going to see much progress.

Syria Deeply: Have there been any successful international efforts to end the sieges?

Szybala: There have been conversations about local cease-fires, but local cease-fires do not necessarily coincide with the end of the siege. Cease-fires cannot be effective in the way they’ve been practiced in Syria so far.

Just because the firing has stopped doesn’t mean access to aid has opened. In Moadamiya at the end of 2014, we saw a negotiated local cease-fire, and the city was subsequently removed from U.N.OCHA’s besieged list. However, when the government sent in its news crews to videotape, the citizens of Moadamiya came out to protest peacefully for the release of their detainees, which was part of the terms of the cease-fire, and the government immediately clamped down the exits and put the city under complete siege and resumed shelling. Moadamiya is completely besieged, but it’s not on the U.N. besieged list.

In the old city of Homs, a lot of the people were displaced and the area was completely emptied, so it wasn’t a cease-fire so much as an evacuation. A lot of the displaced were moved to al-Waer in Homs, which was then besieged. We’ve seen the same thing in Damascus, where people are displaced from one besieged area and the community to which they are displaced was then put under siege. Men from besieged areas that have experienced cease-fires have disappeared into prisons and never been seen again,

Szybala: The U.N. agencies should immediately revisit their besieged designations to consider inclusion of the additional 38 besieged areas designated by SAMS and to verify their population estimates, which currently understate the magnitude of the crisis.

The reports also cautions against changing the besieged status of communities once local cease-fire arrangements have been made, because often these agreements do not result in unfettered humanitarian access.

Additionally, the U.N. General Security does have a voice and role in maintaining peace and security when the Security Council is deadlocked on Syria. We would like the General Security to hold a uniting-for-peace special session, which is a rare move, but it would be a powerful message.

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